Single-cell analysis reveals HBV-specific PD-1+CD8+ TRM cells in tumor borders are associated with HBV-related hepatic damage and fibrosis in HCC patients

Immune checkpoint blockade (ICB) treatment of hepatocellular carcinoma (HCC) patients with hepatitis B virus (HBV) infection may activate viral-specific T cells to attack HBV infected hepatocytes and thus induce immune-related liver injury. Therefore, it is important to deeply understand the impacts of HBV infection on HCC immune microenvironment in order to better design effective immunotherapies for HBV⁺ (HBV infected) HCC patients. Here, We performed cytometry by time-of-flight (CyTOF) analyses to characterize the distinct immune compositions of HCC tumors, tumor borders, and their associations with HCC/HBV related clinical characteristics. We identified 31 distinct immune clusters and found significant associations between immune signatures with clinicopathological features of HCC. We further revealed the HBV infection had more effects on shaping immune compositions in tumor borders than in tumors, with the significant enrichment of HBV-specific PD-1⁺CD8⁺ tissue-resident memory T (T_RM) cells in tumor borders of HBV⁺ patients. We confirmed this subset with a more exhausted phenotype and respond more actively under anti-PD-L1 treatment, suggesting its involvement in immune-related liver injury induced by ICB treatment to HBV⁺ HCC patients. Our study shows it may be necessary to consider antiviral prophylaxis for HBV⁺ HCC patients receiving ICB treatment.

Prospective validation of the Eastern Staging in predicting survival after surgical resection for patients with hepatocellular carcinoma: a multicenter study from China

BACKGROUND

The Eastern Staging System, which was specially developed for patients undergoing surgical resection for hepatocellular carcinoma (HCC), has been proposed for more than ten years. To prospectively validate the predictive accuracy of the Eastern staging on long-term survival after HCC resection.

METHODS

Patients who underwent hepatectomy for HCC from 2011 to 2020 at 10 Chinese hospitals were identified from a prospectively collected database. The survival predictive accuracy was evaluated and compared between the Eastern Staging with six other staging systems, including the JIS, BCLC, Okuda, CLIP, 8th AJCC TNM, and HKLC staging.

RESULTS

Among 2365 patients, the 1-, 3-, and 5-year overall survival rates were 84.2%, 64.5%, and 52.6%, respectively. Among these seven staging systems, the Eastern staging was associated with the best monotonicity of gradients (linear trend χ²: 408.5) and homogeneity (likelihood ratio χ²: 447.3), and the highest discriminatory ability (the areas under curves for 1-, 3-, and 5-year mortality: 0.776, 0.787, and 0.768, respectively). In addition, the Eastern staging was the most informative staging system in predicting survival (Akaike information criterion: 2982.33).

CONCLUSION

Using a large multicenter prospectively collected database, the Eastern Staging was found to show the best predictive accuracy on long-term overall survival in patients with resectable HCC than the other 6 commonly-used staging systems.

Biomarkers for hepatocellular carcinoma based on body fluids and feces

Novel non-/minimally-invasive and effective approaches are urgently needed to supplement and improve current strategies for diagnosis and management of hepatocellular carcinoma (HCC). Overwhelming evidence from published studies on HCC has documented that multiple molecular biomarkers detected in body fluids and feces can be utilized in early-diagnosis, predicting responses to specific therapies, evaluating prognosis before or after therapy, as well as serving as novel therapeutic targets. Detection and analysis of proteins, metabolites, circulating nucleic acids, circulating tumor cells, and extracellular vesicles in body fluids (e.g., blood and urine) and gut microbiota (e.g., in feces) have excellent capabilities to improve different aspects of management of HCC. Numerous studies have been devoted in identifying more promising candidate biomarkers and therapeutic targets for diagnosis, treatment, and monitoring responses of HCC to conventional therapies, most of which may improve diagnosis and management of HCC in the future. This review aimed to summarize recent advances in utilizing these biomarkers in HCC and discuss their clinical significance.

Early diagnosis and therapeutic strategies for hepatocellular carcinoma: From bench to bedside

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related deaths worldwide. The prognosis of patients with HCC remains poor largely due to the late diagnosis and lack of effective treatments. Despite being widely used, alpha-fetoprotein serology and ultrasonography have limited diagnostic performance for early-stage HCC. The emergence of omics strategies has contributed to significant advances in the development of non-invasive biomarkers for the early diagnosis of HCC including proteins, metabolites, circulating tumor deoxyribonucleic acid, and circulating non-coding ribonucleic acid. Early diagnosis is beneficial to patients as it increases the proportion who can be treated with curative treatment, thus prolonging survival outcomes. Currently, multiple clinical trials involving locoregional, systemic therapies, and combinations of these modalities are changing therapeutic strategies for different stage HCC. Success in several preclinical trials that involve immunotherapeutic innovations has created the potential to complement and enforce other treatment strategies in the future. This review summarizes the most recent advances in non-invasive early molecular detection, current therapy strategies, and potential immunotherapeutic innovations of HCC.

Preoperative Inversed Albumin-to-Globulin Ratio Predicts Worse Oncologic Prognosis Following Curative Hepatectomy for Hepatocellular Carcinoma

Background

A normal albumin-to-globulin ratio (NAGR) in serum is greater than 1. Inversed albumin-to-globulin ratio (IAGR < 1) indicates poor synthetic liver function or malnutrition. The aim of this study is to evaluate whether preoperative IAGR was associated with worse oncologic survival after hepatectomy for hepatocellular carcinoma (HCC).

Patients and Methods

Patients who underwent curative hepatectomy for HCC between 2009 and 2016 in four centers were divided into the IAGR and NAGR groups based on their preoperative levels, and their clinical characteristics and long-term survival outcomes were compared. Univariable and multivariable Cox regression analyses were performed to identify risk factors of overall survival (OS) and recurrence-free survival (RFS).

Results

Of 693 enrolled patients, 136 (19.6%) were in the IAGR group. Their 5-year OS and RFS rates were 31.6% and 21.3%, respectively, which were significantly worse than the NAGR group (43.4% and 28.7%, both P < 0.001). The area under the receiver operating characteristic curves in predicting 5-year OS and RFS using the albumin-to-globulin ratio were 0.68 and 0.67, respectively, which were significantly higher than albumin (0.60 and 0.59), globulin (0.56 and 0.57), Child-Pugh grading (0.61 and 0.60), Model for End-Stage Liver Disease Score (0.59 and 0.58), and Albumin-Bilirubin grading (0.64 and 0.63). Multivariable analyses identified that preoperative IAGR was independently associated with worse OS (HR: 1.444, 95% confidence interval (CI): 1.125–1.854, P = 0.004) and RFS (HR: 1.463, 95% CI: 1.159–1.848, P = 0.001).

Conclusion

Preoperative IAGR was useful in predicting worse OS and RFS in patients who underwent curative hepatectomy for HCC.

Right posteroinferior bile duct angulation correlates with bile duct stone occurrence in patients with hepatolithiasis

PURPOSE

This study aimed to examine the correlation between right posteroinferior bile duct (RPBD) angulation and the occurrence of bile duct stones in patients with hepatolithiasis.

METHODS

Patients presenting with hepatolithiasis in our hospital from January 2011 to July 2016 were divided into two groups according to whether their RPBD was affected by stones. A statistical analysis for the relevant factors associated with bile duct stone formation in the RPBD was performed.

RESULTS

The binary logistic regression results showed that stenosis of the right hepatic duct [odds ratio (OR): 7.313; 95% confidence interval (CI) 4.131-12.945)] and the angle of the RPBD (OR 0.896; 95%CI 0.877-0.916) were risk factors associated with the formation of RPBD stones. Further, the receiver operating characteristic curve indicated that, when the angle of the RPBD was less than 44.58°, stones were able to form more easily in the RPBD.

CONCLUSION

The occurrence of bile duct stones is well correlated with sharp bile duct angulation.

The impact of resection margin and microvascular invasion on long-term prognosis after curative resection of hepatocellular carcinoma: a multi-institutional study

BACKGROUND

The resection margin (RM) status and microscopic vascular invasion (MVI) are known prognostic factors for hepatocellular carcinoma (HCC). An enhanced understanding of their impact on long-term prognosis is required to improve oncological outcomes.

METHODS

Using multi-institutional data, the different impact of the RM status (narrow, <1 cm, or wide, ≥1 cm) and MVI (positive or negative) on overall survival (OS) and recurrence-free survival (RFS) after curative liver resection of solitary HCC without macrovascular invasion was analyzed.

RESULTS

In 801 patients, 306 (38%) had a narrow RM and 352 (44%) had positive MVI. The median OS and RFS were 109.8 and 74.8 months in patients with wide RM & negative MVI, 93.5 and 53.1 months with wide RM & positive MVI, 79.2 and 41.6 months with narrow RM & negative MVI, and 69.2 and 37.5 months with narrow RM & positive MVI (both P < 0.01). On multivariable analyses, narrow RM & positive MVI had the highest hazard ratio with reduced OS and RFS (HR 2.96, 95% CI 2.11-4.17, and HR 3.15, 95% CI, 2.09-4.67, respectively).

CONCLUSIONS

Concomitant having narrow RM and positive MVI increases the risks of postoperative death and recurrence by about 2-fold in patients with solitary HCC.

Preoperative prealbumin level as an independent predictor of long-term prognosis after liver resection for hepatocellular carcinoma: a multi-institutional study

BACKGROUND

Serum prealbumin is a sensitive and stable marker for nutritional status and liver function. Whether preoperative prealbumin level is associated with long-term prognosis in patients undergoing liver resection for hepatocellular carcinoma (HCC) is unclear.

METHODS

Patients who underwent liver resection for HCC between 2001 and 2014 at six institutions were enrolled. These patients were divided into the low and normal prealbumin groups using a cut-off value of 170 mg/L for preoperative prealbumin level. The overall survival (OS) and recurrence-free survival (RFS) were compared between them.

RESULTS

In 1483 patients, 437 (29%) had a low prealbumin level. The 3- and 5-year OS and RFS rates of patients in the low-prealbumin group were 57 and 31%, and 40 and 20%, respectively, which were significantly poorer than those in the normal-prealbumin group (76 and 43%, and 56 and 28%, respectively, both p < 0.001). Multivariable Cox-regression analyses revealed that preoperative prealbumin level was an independent predictor of OS (HR, 1.45, 95% CI: 1.24-1.70, p <0.001) and RFS (HR, 1.28, 95% CI: 1.10-1.48, p <0.001).

CONCLUSIONS

Preoperative prealbumin level could be used in predicting long-term prognosis for patients undergoing liver resection for HCC.

Serum ARCHITECT PIVKA-II reference interval in healthy Chinese adults: Sub-analysis from a prospective multicenter study

BACKGROUND

Protein induced by vitamin K absence or antagonist-II (PIVKA-II) has been widely used as a biomarker for liver cancer diagnosis in Japan for decades. However, the reference intervals for serum ARCHITECT PIVKA-II have not been established in the Chinese population. Thus, this study aimed to measure serum PIVKA-II levels in healthy Chinese subjects.

METHODS

This is a sub-analysis from the prospective, cross-sectional and multicenter study (ClinicalTrials.gov Identifier: NCT03047603). A total of 892 healthy participants (777 Han and 115 Uygur) with complete health checkup results were recruited from 7 regional centers in China. Serum PIVKA-II level was measured by ARCHITECT immunoassay. All 95% reference ranges were estimated by nonparametric method.

RESULTS

The distribution of PIVKA-II values showed significant difference with ethnicity and sex, but not age. The 95% reference range of PIVKA-II was 13.62-40.38 mAU/ml in Han Chinese subjects and 15.16-53.74 mAU/ml in Uygur subjects. PIVKA-II level was significantly higher in males than in females (P < 0.001). The 95% reference range of PIVKA-II was 15.39-42.01 mAU/ml in Han males while 11.96-39.13 mAU/ml in Han females.

CONCLUSIONS

The reference interval of serum PIVKA-II on the Architect platform was established in healthy Chinese adults. This will be valuable for future clinical and laboratory studies performed using the Architect analyzer. Different ethnic backgrounds and analytical methods underline the need for redefining the reference interval of analytes such as PIVKA-II, in central laboratories in different countries.

Surgical resection versus transarterial chemoembolization for BCLC intermediate stage hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND & OBJECTIVE

Transarterial chemoembolization (TACE) is recommended as the first-line therapy for intermediate stage hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer (BCLC) algorithm. However, in clinical practice, many such patients undergo surgical resection. A meta-analysis with a systematic search of the medical literature was conducted to compare these two procedures for BCLC intermediate stage HCC.

METHODS

PubMed, Embase, Medline and Cochrane library were searched for studies comparing surgical resection with TACE for BCLC intermediate stage HCC that were published before December 2016. The primary outcome was overall survival, and the secondary outcomes were postoperative complications and 30-day mortality.

RESULTS

This meta-analysis included 9 studies with 2619 patients (surgical resection, n = 1204 (46%) and TACE, n = 1415 (54%)). When compared with the TACE group, the pooled hazard ratio (HR) for the 1, 3 and 5-year OS rates in patients who underwent surgical resection were 0.62 (95% CI 0.51-0.75, P = 0.39; I2 = 6%, P < 0.001), 0.58 (95% CI 0.51-0.67, P = 0.25; I2 = 22%, P < 0.001) and 0.59 (95% CI 0.54-0.64, P = 0.18; I2 = 20%, P < 0.001). No significant differences in the pooled odds ratios (OR) were found between surgical resection and TACE in postoperative complications and 30-day mortality [OR 1.23 (95% CI 0.87 to 1.74, P = 0.390; I2 = 0%, P = 0.240) and OR 1.11 (95% CI 0.60 to 2.04, P = 0.89; I2 = 0%, P = 0.740), respectively].

CONCLUSION

This meta-analysis on studies on Asian HCC patients demonstrated surgical resection had better overall survival than TACE for patients with intermediate stage HCC, without any significant increase in postoperative complication or 30-day mortality rates. Further studies are needed to validate these results on Western patients, moreover, a reappraisal of the recommended treatments for BCLC intermediate stage HCC should be considered.

Dysregulated fatty acid metabolism in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most frequent and deadly malignancies worldwide. Studies are urgently needed on its molecular pathogenesis and biological characteristics. Dysregulation of fatty acid (FA) metabolism, in which aberrant activation of oncogenic signaling pathways alters the expression and activity of lipid-metabolizing enzymes, is an emerging hallmark of cancer cells, and it may be involved in HCC development and progression. The current review summarizes what is known about dysregulated FA metabolism in HCC and pathways through which this dysregulation may regulate HCC survival and growth. Our understanding of dysregulated FA metabolism and associated signaling pathways may contribute to the development of novel and efficient antitumor approaches for patients with HCC.

Clinical application of protein induced by vitamin K antagonist-II as a biomarker in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. Early diagnosis improves the prognosis. Protein induced by vitamin K antagonist-II (PIVKA-II) is an effective serum biomarker for HCC diagnosis and prognosis. Combined with another serum biomarker α-fetoprotein (AFP), the sensitivity and specificity of HCC diagnosis can be improved to a maximum of 94 and 98.5 %, respectively. PIVKA-II alone or in combination with AFP and/or AFP-L3 was effective in predicting the treatment response and clinical outcome of curative hepatic resection, chemotherapy, targeted therapy, radiotherapy, and liver transplantation. Japanese clinical guidelines recommend the combined use of PIVKA-II and AFP for the diagnosis of HCC, management of high-risk population, and prognosis of anticancer treatment. Further, PIVKA-II as a functional target promoted HCC cell proliferation, invasion, and metastasis by activating c-Met and other signal transduction pathways. Inhibition of PIVKA-II may provide a selective and effective therapy for HCC.

Epidemiology and surgical management of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a rare hepatobiliary malignancy arising from the epithelial cells of the intrahepatic bile ducts. The increased incidence of ICC worldwide may reflect both a true increase and the earlier detection of the disease. Despite the advances in modern surgical care, the curative chance for ICC remained suboptimal: tumor-free margins are hard to achieve due to tumor locations, and technical challenges and recurrence, either local or distant, may hamper the resectability in a large number of patients. Lymph node involvement and vascular invasions are considered negative predictive factors for survival of ICC patients. This review discusses the epidemiology, risk factors and surgical management of ICCs, and mainly focuses on outcomes and factors associated with surgical treatment.

Surgical treatment of xanthogranulomatous cholecystitis: experience in 33 cases

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe fibrosis and foam cells, and can be a cause of difficulty in cholecystectomy. Patients with XGC are frequently misdiagnosed intraoperatively as having carcinoma of the gallbladder and are treated with extensive excision. This study aimed at providing proper surgical treatment for patients with XGC.

METHODS

The clinical data of 33 patients with XGC definitely diagnosed by pathological examination over a period of 10 years were analyzed retrospectively (mean age of onset, 60 years; male/female ratio, 1.5:1).

RESULTS

Preoperatively, the 33 patients were examined by abdominal B-ultrasonography while 20 of them were further examined by computed tomography (CT). Intraoperatively, XGC associated with cholecystolithiasis was found in 97.0% of the patients, thickening of the gallbladder wall in 90.9%, xanthogranulomatous tissue invading into other tissues in 87.9%, XGC associated with choledocholithiasis in 15.2%, and Mirizzi syndrome in 9.1%. In addition, a gallbladder fistula was observed in 4 patients. Open cholecystectomy was performed on 15 patients, partial cholecystectomy on 7, cholecystectomy and partial liver wedge resection on 5, and gallbladder cancer radical correction on 6. The intraoperative misdiagnosis rate was 24.2%. Frozen-section examination was carried out in 9 patients. Postoperative complications were observed in 5 patients.

CONCLUSIONS

XGC is difficult to diagnose either preoperatively or intraoperatively and definite diagnosis depends exclusively on pathological examination. Firm adhesions of the gallbladder to neighboring organs and tissues are common and lead to difficulty in surgical treatments. The mode of operation depends on specific conditions in varying cases, and since frozen-section examination plays an important role in determining the nature of the lesions, intraoperative frozen-section examination should be carried out to differentiate XGC from carcinoma of the gallbladder.